Some critics of psychiatry have argued that the medical model is a relatively modern invention, (13) but as the Oxford philosopher and classicist Anthony Kenny has shown, the idea that some forms of madness might be generically linked to bodily disease dates back to ancient Greece. (1i> At this time, however, and throughout history, the medical model has had to compete with a variety of spiritual or moral interpretations. (15) With the rise of modern psychiatry in the late nineteenth and early twentieth centuries it seemed that the medical model had triumphed. Yet even at the time, Karl Jaspers, one of the architects of modern scientific psychiatry, warned against naive biologism;(16) far from withering away, it was precisely when effective drugs and credible disease theories were finally coming into their own, in the 1960s and 1970s, that alternative models offered by the radical antipsychiatry movement were most influential.
Radical antipsychiatry emphasized two morally relevant features of mental disorder: agency and values. (1Z>
• An indirect reflection of the moral model in antipsychiatry was the importance it attached, in one form or another, to the notion of agency. Those suffering from mental disorder, antipsychiatry insisted, might be victims variously of labelling, of oppressive family dynamics, or of coercive societal or political forces. But they remained moral agents in their own right, capable of actively engaging with their problems, rather than patients, the passive victims of a disease process.
• A more direct reflection of the moral model in antipsychiatry was the significance it attached to the values by which mental disorders are (partly) defined. One prominent proponent, Thomas Szasz, based his conclusion that mental illness is a 'myth' directly on the claim that a diagnosis of mental illness is grounded on value judgements. Genuine illnesses, he argued, are defined by scientific norms derived from anatomy and physiology, whereas mental illness is defined by norms which are 'psycho-social, ethical and legal' in character.(18) Opponents of Szasz, such as R. E. Kendell,(1i> counter-argued that mental illness, properly understood, can be defined by the same biological norms (of reduced life and/or reproductive expectations) as physical illness.
With major advances in neuroscience, such as neuroimaging, antipsychotic medications, and genetics, it has again become commonplace among 'biological' psychiatrists to assume that antipsychiatry is dead. Radical antipsychiatry is certainly less influential since the 1980s. Yet many of its themes have been absorbed into the mainstream. The importance of agency is evident, for example, in the widespread use of cognitive-behavioural therapies (restoring agency through the acquisition of self-management skills), and in the growing influence of the 'user's voice'. Similarly, far from disappearing, the value judgements involved in psychiatric diagnosis have become ever more transparent. In ICD-9(20) the relevant value judgements were largely implicit. But in DSM-IV(21) the definitions of a number of specific disorders incorporate evaluative criteria. Criterion B for schizophrenia, for example, requires not just a change but a deterioration in social or occupational functioning; and antisocial personality disorder is defined by disregard for the ' rights of others' and by failure to 'conform to social norms' (emphases added).
DSM-IV rightly emphasizes that mental disorders should not be diagnosed solely by reference to social norms. Besides disease, a wide range of other states, such as delinquency and despair, are defined in part (though only in part) by negative value judgements. The deterioration of functioning by which schizophrenia is (partly) defined under Criterion B, or the norm violations of antisocial personality disorder, must therefore be, in DSM-IV's phrase, 'clinically significant'. They must be symptoms of a 'dysfunction in the individual (emphasis added—a much disputed phrase but implying a conceptual link between the medical model and loss of agency). What all this amounts to, then, is that in DSM-IV a negative value judgement, in these and similar cases, is not sufficient for a diagnosis of mental disorder. But by the same token, according to DSM-IV, a negative value judgement is necessary.
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